Tibial Shaft Fractures in Children and Adolescents

Casting, elastic intramedullary nailing or external fixation in pediatric tibial shaft fractures: which is the most appropriate treatment? A multicenter study

The main objective of this study was to retrospectively evaluate and compare the outcomes and complications of displaced closed tibial fractures in children treated by CRC (closed reduction and casting), elastic stable intramedullary nailing (ESIN) or external fixation (EF). One hundred twenty-three consecutive children were treated for displaced closed tibia shaft fracture from July 2014 and January 2020 at two different institutions. Seventy-five of them met the inclusion criteria and were included in the study: 30 (40%) patients were treated with CRC, 33 (44%) with ESIN, and 12 with EF (16%). All clinical and radiographic outcomes and complications were registered and compared. The three groups did not differ with regard to gender, affected side, fracture site and associated fibula fracture. The age at the time of treatment in the CRC group was statistically lower than in ESIN and EF groups (8.43 ± 3.52 years vs. 10.39 ± 2.56 years vs. 11.08 ± 3.55 years, respectively). Immobilization time and time to partial and total weight bearing were significantly reduced in ESIN and EF groups compared to CRC group ( P  < 0.05). Overall, no statistically significant differences were found between the three groups regarding complication rate and clinical and radiographic outcomes between the three groups. However, in CRC group, 3 patients (10%) had secondary fracture displacement and underwent ESIN. Surgical treatment is not contraindicated in children with displaced tibia shaft fractures. EF and ESIN provide earlier mobilization and weight-bearing recovery than CRC. However, apart from that, nonoperative treatment was as efficacious as surgical treatment.

Overlooked valgus bowing deformity in pediatric tibial shaft fractures with/without fibular involvement: Cause residual valgus alignment in 2-year follow-up

BACKGROUND

Children with a tibial shaft fracture often present with valgus malalignment, even when anatomical reduction had been achieved at the fracture site. Pediatric bony structure has more elastic bones than that of adults, it can cause bowing deformity. Therefore, we evaluated pediatric tibial shaft fracture for the presence of bowing deformity, associated risk factors, and its clinical significance.

HYPOTHESIS

There is an overlooked bowing deformity in pediatric tibial shaft fracture.

PATIENTS AND METHODS

Fifty-seven tibial shaft fracture patients aged 2 to 15 years with Risser stage 0 were retrospectively reviewed. Clinicoradiologic factors and radiographs taken within 3 post-traumatic months and at 2 years were assessed. To evaluate the tibial bowing deformity, the tibial interphyseal angle and tibial shaft angle were measured, and their differences were calculated as a tibial bowing angle.

RESULTS

Multivariate analysis revealed the tibial shaft fracture with fibular involvement is significantly associated with a higher initial tibial bowing angle (valgus deformity). The tibial bowing angle did not change over 2-year follow-up. A high initial tibial bowing angle (≥ 5°) was a significant risk factor for the persistence of valgus malalignment.

DISCUSSION

Pediatric tibial shaft fractures with/without fibular involvement carry the risk of valgus bowing deformity, which may not develop during post-traumatic growth but may be present at the time of injury. The risk is high if the tibial fracture is accompanied by a fibular fracture. This tibial deformity presents limited remodeling potential at 2-year follow-up.

LEVEL OF EVIDENCE

IV; retrospective study.

Patient-reported outcomes of adolescents with tibia shaft fractures: comparison of closed reduction and casting vs. elastic stable intramedullary nailing

Tibial shaft fractures are the third most common pediatric long bone fractures. Closed reduction and casting (CRC) is considered initial treatment in this population, however, surgical management using elastic stable intramedullary nailing (ESIN) is also used in adolescents. This study compared patient-reported outcomes in a cohort of adolescents with tibia fractures treated with ESIN or CRC. This single-center retrospective study gathered adolescent patients 10-18 years of age with closed tibia shaft fractures between the years 2015 and 2021 treated by either CRC or ESIN. Measured outcomes include patient demographics, overall casting time, time to full weight bearing, time to full healing, radiographic healing, complications (loss of reduction, malunion >5° and >10°) and Patient-Reported Outcomes Measurement Information System (PROMIS) scores. A total of 141 patients (68% male) were included, with 31 receiving ESIN and 110 having CRC. Patient demographics were similar across groups. At follow-up, CRC had a significant shorter time to healing (11 vs. 15 weeks), but an increased casting duration (7 vs. 4 weeks). Finally, the ESIN group had significantly greater pre-intervention angulation, displacement, and shortening. In both interventions, mobility and pain interference scores showed significant improvements from baseline (2 weeks post-op) at 12, 16, and 24 weeks. No statistically significant differences were noted between CRC and ESIN groups across PROMIS domains of pain interference and mobility. CRC and ESIN are effective in improving pain and mobility in adolescent diaphyseal tibia fractures, but neither intervention is superior based on PROMIS scores at 12, 16 and 24+ weeks. From a patient standpoint, we demonstrate that neither treatment is superior in achieving better-perceived mobility or decreasing pain sooner. Level of Evidence: Level III.

External fixator as a safe method in the treatment of distal tibial fractures in children

OBJECTIVE

The objective of this study is to evaluate the functional and radiological results of external fixator application in the treatment of distal tibial metaphyseal diaphyseal junction (MDJ) fractures in children and to analyze differences between stable and unstable fractures.

METHODS

Medical records of children with distal tibial MDJ fracture confirmed by imaging from January 2015 to November 2021 were retrospectively analyzed. Patients were divided into stable and unstable groups and parameters, including clinical and imaging data and Tornetta ankle score were compared.

RESULTS

Twenty-five children, comprising 13 with stable and 12 with unstable fractures, were included in our study. The mean age was 7 years (range, 2-13.1 years), and there were 17 males and 8 females. All children had closed reduction, and the basic clinical data of the two groups were comparable. Stable fractures showed shorter intraoperative fluoroscopy, operation, and fracture healing times than unstable fractures. No significant difference in Tornetta ankle score was observed. Twenty-two patients had excellent ankle score, and three had a good ankle score, for a combined incidence of 100%. Two patients in the stable fracture group and one in the unstable fracture group developed a pin site infection, and one patient with unstable fracture showed a length discrepancy (discrepancy<1 cm).

CONCLUSION

External fixator is safe and effective for the treatment of distal tibial MDJ fractures, whether the fracture is stable or not. It has the advantages of minimally invasive, excellent ankle function score, few major complications, needless auxiliary cast fixation, and early functional exercise and weight bearing.

LEVEL OF EVIDENCE

Level IV.

Assessing the effectiveness of intramedullary nailing for tibial shaft fractures in a low-income setting: a prospective study in Yemen

BACKGROUND

Tibial shaft fractures are common injuries that can be treated with various methods, including interlocked intramedullary nail (IMN). However, there is limited data on the clinical outcomes of IMN for tibial shaft fractures in Yemen.

OBJECTIVE

To evaluate the clinical outcomes of primary IMN for tibial shaft fractures in Yemen.

METHODS

This was a prospective study of 134 patients who underwent primary IMN for tibial shaft fractures et al.-Thawra Modern General Hospital in Sana'a, Yemen, between June 2016 and June 2020. The patients were between 18 and 70 years old, and the fractures were classified according to the AO classification system. The fractures were treated with IMN using a standard technique. The patients were followed up for a minimum of 2 years. The outcome measures included union time, complications, and functional scores.

RESULTS

The mean union time was 17 weeks. The overall complication rate was 18.7%. The most common complications were infection (8.2%), delayed union (6.7%), and nonunion (3.7%). The mean functional scores at the final follow-up were 91.4 for the Knee Society Score and 90.2 for the American Orthopaedic Foot and Ankle Society Score.

CONCLUSION

Primary IMN is an effective and reliable method for treating tibial shaft fractures in Yemen, with acceptable union time, complication rate, and functional outcomes.

Femoral Shaft Fractures in Children: Exploring Treatment Outcomes and Implications

INTRODUCTION

Femoral shaft fractures significantly impact children and families, posing a significant challenge for pediatric patients. The prevalence of limb shortening in femur shaft fractures treated with hip spica casting in our group, however, has not been the subject of many recent investigations.

AIMS

By comparing the prevalence of limb shortening to various age groups and common pediatric injury patterns, this research seeks to close this information gap.

METHODS

This research, which lasted six months and was done at the Orthopedics Unit of Khyber Teaching Hospital Peshawar, Pakistan, included 129 children with closed femur shaft fractures who were between the ages of one and six. Clinical assessments, radiological examinations, and hip spica casting, all supervised by experienced orthopedic surgeons, were carried out. Senior postgraduate trainees oversaw the study's findings.

RESULTS

The results unveiled key insights into the study population. Among the findings, 33% (n=43) of the children were aged one to three years, while 67% (n=86) fell within the three to six years age range. Gender distribution revealed that 72% (n= 93) were male. In terms of mechanism, 22% (n=28) of fractures were attributed to road traffic accidents, 69% (n=89) were the result of falls, and 5% (n=12) were due to other causes. Notably, 19% (n=29) of the children exhibited limb shortening.

CONCLUSION

This study contributes significantly to the understanding of femur shaft fractures in children, shedding light on their complex dynamics. The study enhances our understanding of pediatric femur shaft fractures. We found that 19% of children exhibited limb shortening, underscoring the need for targeted treatment strategies. These insights can significantly improve patient care and treatment protocols for this challenging condition, benefiting both children and their families.

Tibial shaft fractures in children: flexible intramedullary nailing in growing children especially weighing 50 kg (110 lbs) or more

Currently the gold standard in surgical treatment of displaced tibial shaft fractures in children with open growth cartilage is elastic stable intramedullary nailing (ESIN). The purpose of this study is the analysis of indications, complications, and duration of treatment using intramedullary flexible nails in children who are still growing but especially weighing 50 kg or more. Hospital records from 2017 to 2020 were retrospectively reviewed to identify the children from 4 to 17 years of age with displaced tibial shaft fractures admitted to the hospital. Only children with open growth cartilage, with a minimum of 6 months of follow-up and complete clinical data, were included. Studies of 91 children xwere analyzed. The average patient age at the time of the injury was 10.88 ± 2.82 years. In the entire group, 31.9% children weighed 50 kg or more, and 68.1% of the children were below this weight. All children were treated using ESIN. The mean time to nail removal was 8.4 ± 4.09 months in the whole group of children stabilized with ESIN. There were no differences in the two groups depending on the weight ( P = 0.637). Only two adverse events were observed. This study demonstrates that the use of ESIN in displaced tibial shaft fractures in growing children weighing 50 kg or more is acceptable and safe. The discussion to be made is whether it is still an acceptable method of treatment for this type of fracture due to the progressive obesity epidemic in children and adolescents.

Paediatric tibial shaft fractures: an instructional review for the FRCS exam

This instructional review presents the literature and guidelines relevant to the classification, management and prognosis of paediatric tibial shaft fractures at a level appropriate for the FRCS exit examination in Trauma and Orthopaedic surgery.

Displaced Tibia Fractures in Adolescents: Closed Reduction and Casting Versus Flexible Intramedullary Nails

INTRODUCTION

Although there has been a recent trend towards the operative intervention of pediatric diaphyseal tibial fractures, there is sparse literature that supports this trend. This study compares the outcomes in children between 10 and 18 years of age with diaphyseal tibial fractures who undergo nonoperative treatment with closed reduction and casting (CRC) to those who undergo operative treatment with flexible intramedullary nailing.

METHODS

A retrospective chart review was performed of all patients between 10 and 18 years of age who underwent treatment for tibia fractures at the authors home institution between 2005 and 2018. Radiographs and medical records were reviewed for the duration of immobilization, time to fracture healing and complications including delayed union, malunion, nonunion, and surgical site infection. All statistical analysis was performed using an αof 0.05.

RESULTS

One hundred forty one patients (81.8% males) were included in the final analysis. Patients treated with flexible nailing took an average of 7 weeks ( P <0.001) longer than patients treated with CRC to achieve radiographic healing. The average time to full weight-bearing activities was longer by 1 week in the patients treated nonoperatively with CRC ( P =0.001). There was no statistically significant difference in the malunion rates between the 2 groups ( P =0.067), but delayed union and nonunion were exclusively seen in the flexible nailing group. There was a total of 40 complications among 33 (23.4%) patients, most of whom were in the CRC cohort (60.6%, n=20), but there was no statistically significant difference in complication rates between the 2 cohorts.

DISCUSSION

Most adolescents presenting with closed diaphyseal tibial fractures of moderate severity can be successfully treated both nonoperatively with CRC and operatively with flexible intramedullary nailing. However, we recommend an initial attempt at nonoperative treatment be performed in these patients due to the association of more severe complications with flexible nailing.

LEVEL OF EVIDENCE

Level III.

[Risk factors of adverse long-term consequences of tibial shaft fractures in children]

OBJECTIVE

To analyze leg length discrepancy and overgrowth after tibial shaft fractures in children.

MATERIAL AND METHODS

We analyzed medical records of 103 patients younger 14 years old with tibial shaft fractures between January 2003 and November 2018. Treatment included plastering and insertion of titanium elastic nail. To identify the risk factors of leg length discrepancy ≥1 cm and overgrowth ≥1 cm, we performed logistic regression analysis. Statistical analysis was carried out using the SPSS software for Windows.

RESULTS

Gender (p=0.014) and treatment methods (p=0.011) are the most significant predictors of leg length discrepancy and overgrowth. In boys, the risk of leg length discrepancy ≥1 cm was 7.4 times higher than in girls. The risk of leg length discrepancy ≥1 cm was 4.3 times higher after insertion of titanium elastic nail compared to plastering. The risk of overgrowth ≥1 cm was 5.4 times higher in boys than in girls. The risk of overgrowth ≥1 cm was 4.7 times higher after insertion of titanium elastic nail compared to plastering.

CONCLUSION

One should consider the risk of leg length discrepancy and overgrowth in children with tibial shaft fractures. This is especially true for boys undergoing insertion of titanium elastic nail.

[Intraoperative imaging of children and adolescents, for selected fractures and in follow-up after conservative and operative treatment : Part 2 of the results of a nationwide online survey of the Pediatric Traumatology Section of the German Trauma Society]

The indication for radiographic examinations in pediatric and adolescent trauma patients should follow ALARA (as low as reasonably achievable). Because of the effect of radiation on the growing sensitive tissues of these young patients, a strict indication should always be given for radiation use and during controls after fracture repair.

METHODS

An online survey by the Pediatric Traumatology Section (SKT) of the German Trauma Society (DGU) from Nov. 15, 2019, to Feb. 29, 2020, targeting trauma, pediatric, and general surgeons and orthopedic surgeons.

RESULTS

Participants: 788. Intraoperative applications: Collimation 50% always, postprocessing for magnification 40%, pulsed x-ray 47%, and 89% no continuous fluoroscopy; 63% osteosynthesis never directly on image intensifier. Radiographic controls after implant removal never used by 24%. After operated supracondylar humerus fracture, controls are performed up to 6 times. After distal radius greenstick fracture, 40% refrain from further X-ray controls, after conservatively treated clavicular shaft fracture, 55% refrain from further controls, others X-ray several times. After nondisplaced conservatively treated tibial shaft fracture, 63% recommend radiographic control after 1 week in two planes, 24% after 2 weeks, 37% after 4 weeks, and 32% after 6 weeks.

DISCUSSION

The analysis shows that there is no uniform radiological management of children and adolescents with fractures among the respondents. For some indications for the use of radiography, the benefit does not seem evident. The ALARA principle does not seem to be consistently followed.

CONCLUSION

Comparing the documented results of the survey with the consensus results of the SKT, differences are apparent.

Epidemiology and treatment of pediatric tibial fractures in Sweden: a nationwide population-based study on 5828 fractures from the Swedish Fracture Register

Purpose

Pediatric tibial fractures have been described internationally as mainly caused by fall during leisure activities and organized sports and showing a higher incidence in boys. Still, most studies are single center studies or have a small sample size. This study aimed to analyze sex and age distribution, seasonal variation, injury mechanisms and treatment of pediatric tibial fractures based on the nationwide Swedish Fracture Register (SFR).

Methods

All tibial fractures in patients < 16 years at injury and registered in 2015–2019 were extracted from the SFR. We analyzed patient characteristics such as sex and age, injury mechanism, fracture location and treatment.

Results

The study cohort consisted of 5828 pediatric tibial fractures in 5719 patients. Median age of the patients was 7 years and 58% were boys. Shaft fractures were most common, followed by the distal and proximal tibia. The lowest incidence was observed during autumn. The most common cause of injury was fall mostly involving winter sports, stumbles and fall from play equipment. Play/free time and sports were the most common activities, common places of injury were sports facility and home. 1% were open fractures. 78% were treated non-surgically. Screw fixation was performed in 52% of surgically treated fractures, predominantly in the distal segment.

Conclusion

Injury mechanism differs between age groups; play/free time injuries are common in younger children compared with sport activities in older children. Most patients are treated non-surgically. Open fractures are rare. Information on injury patterns is useful working preventively, for example safety work in playgrounds.

Nonoperative Management of Closed Displaced Tibia Shaft Fractures in Patients Under 18 Years of Age: Low Failure Rate

BACKGROUND

Tibial shaft fractures are the third most common pediatric long bone fracture pattern. Historically, these fractures have been initially treated with closed reduction and casting (CRC). Recently, there has been an increasing trend toward surgical intervention as an initial treatment for these injuries. In an effort to better understand whether this trend is warranted, this study seeks to characterize the clinical and radiographic outcomes of a large number of children who underwent nonoperative treatment with CRC as their initial treatment for pediatric tibial shaft fractures at a single tertiary care center.

METHODS

Outcomes measured included final alignment, other procedures performed, length of time to full radiographic healing, and length of time in each method of immobilization before progressing to full weight-bearing status. Patients were separated by ages into the following cohorts during statistical analysis: 4 to 8 years, 9 to 12 years, and 13+ years. Differences between continuous variables were analyzed with independent-samples t tests. χ 2 tests were used to analyze differences in categorical variables. An α<0.05 was considered statistically significant.

RESULTS

A total of 137 patients met our inclusion criteria. The median age was 10.19 years (4.03 to 17.43). The average initial displacement among all age groups was 27.42% (±15.05%). After the initial intervention with CRC, all age groups demonstrated an average of <5 degrees of residual angulation and <20% of residual displacement. Complete radiographic healing was seen in 127 (92.7%) patients by 3 months. Loss of reduction requiring additional clinical intervention was seen in 30 (21.9%) patients with only 5% requiring surgical intervention, whereas malunion was seen in a total of 16 (11.7%) patients at the final visit. There were no cases of compartment syndrome or deep wound infection. Male and initial angulation were the only factors predictive of loss of reduction.

CONCLUSION

Initial intervention with CRC is a safe and effective treatment for the majority of children in all age groups presenting with tibial shaft fractures demonstrating minimal angulation and displacement with surgical intervention being required in only 5% of patients. Further studies are warranted to elucidate the characteristics of patients who may benefit most from initial surgical intervention.

LEVEL OF EVIDENCE

Level III-retrospective study.

Tibial shaft fractures in the adolescents: treatment outcomes and the risk factors for complications

BACKGROUND

Tibial shaft fractures are common injuries in the adolescent age group. The optimal method of treatment in this age group is still controversial. It relies on several factors including patient's age, fracture pattern, fracture location, and the condition of the soft tissue envelope. The purpose of this study was to report the clinical and radiographic outcomes of adolescent tibial shaft fractures treatment at a level-I trauma center.

METHODS

This retrospective study reviewed consecutive patients between 10 and 18 years of age who suffered from tibial shaft fractures between 2009 and 2018 at a level-I trauma center. Outcomes of interest were the successful fracture union (primary outcome) as evaluated by the Radiographic Union Scale in Tibial fractures (RUST) and the complications (secondary outcomes).

RESULTS

Fifty-two consecutive adolescent patients treated for tibial shaft fractures using elastic stable intramedullary nails (ESIN), interlocking nails, plates and screws, external fixators, and casts were included in the study. The mean follow-up period was 27.4 months. There was no statistically significant difference in the union rate and time to fracture union between the different treatment methods. Subject weight, fracture type, and method of treatment were significant predictors for the RUST scores at 12 weeks post-operative. Adolescents with heavier bodyweight correlated with lower RUST scores (p<0.001). Open fractures were associated with significantly longer time to union (p<0.001) and lower RUST scores (p<0.001) compared to closed fractures. The patients treated with interlocking nailing showed higher RUST scores than the casting treatment group (p = 0.01). There were no statistically significant differences in complication rates between the fixation methods. Union time was significantly longer with complications than without complications (p = 0.01). Open fractures had higher complication rates compared to closed fractures. In the multivariate logistic model, patients with open fracture were 5.5 times more likely to have complications (OR=5.46; p = 0.04).

CONCLUSION

Tibial shaft fractures in adolescents can be treated with several methods including ESIN, interlocking nail, plate and screws, external fixation, and casting. All are valid treatments for adolescent tibial shaft fractures and can achieve favorable outcomes. No single treatment method applies to all patients. Each method has advantages, disadvantages, and specific indications.

Which is the better choice for open tibial shaft fracture in overweight adolescent with open physis: A comparative study of external fixator plus elastic stable intramedullary nail versus external fixator alone

PURPOSE

To compare the clinical outcomes of external fixator + elastic stable intramedullary nail (EF+ESIN) vs. external fixator (EF) in the treatment for open tibial shaft fracture in overweight adolescents.

METHODS

Patients of open tibial shaft fractures younger than 14 years old with body weight over 50 Kg treated with EF + ESIN or EF at our institute from 2010 to 2018 were reviewed. Patients with Gustilo Type III open fractures, pathological fractures, previous fracture or instrumentation in the operative leg were excluded. Baseline information and clinical data were collected from the hospital database and during out-patient visits.

RESULTS

Forty-six patients, including 27 males and 19 females, were included in the EF group, whereas 35 patients, including 18 males and 17 females, were included in the EF + ESIN group (p = 0.527). The incidence of superficial infection was higher in the EF group (26/46, 56.5%) than the EF + ESIN group (12/35, 34.3%), p < 0.001. The frontal and sagittal angulation was higher in the EF group (p < 0.001), but the degrees in both groups were within the acceptable range. The union time was longer in the EF group (68.0 ± 12.7, d) than the EF + ESIN group (61.9 ± 11.9), p < 0.001. The retaining of EF (11.9 ± 3.2, w) was longer in the EF group than the EF +ESIN group (5.7 ± 1.2, w), p < 0.001.

CONCLUSION

EF+ESIN is a safe and alternative choice for selected overweight adolescents with open tibial shaft fracture.

Modern management of paediatric tibial shaft fractures: an evidence-based update

AIMS

This review provides a summary of recent evidence surrounding the treatment of paediatric tibial shaft fractures and presents an algorithm to aid management of these injuries. This article reviews the relevant anatomy, epidemiology and aetiology of tibial shaft fractures and summarises contemporary treatment principles. Management recommendations and supporting evidence are given for fractures according to age (< 18 months, 18 months-5 years, 6-12 years, and 13-18 years). The relative merits of casting, plate fixation, elastic and rigid intramedullary nailing, and external fixation are discussed. Special attention is paid to the management of open tibial shaft fractures and to complications including infection and acute compartment syndrome.

CONCLUSIONS

There has been a shift away from non-operative management of paediatric tibial shaft fractures over the last 30 years. However, recent evidence highlights that a non-operative approach produces acceptable outcomes when used in simple closed fractures at any age. Operative management may be indicated for unstable fractures where satisfactory alignment cannot be maintained or in specific circumstances including open injuries and polytrauma. Open injuries require urgent assessment by a combined orthopaedic and plastic surgery team at a specialist tertiary centre.

Calcaneal skeletal traction versus elastic intramedullary nailing of displaced tibial shaft fractures in children

BACKGROUND

The objective of this study was to compare the outcomes and complications of patients who underwent either the calcaneal skeletal traction (CST) or the elastic intramedullary nails (EIN) procedure.

METHODS

We retrospectively reviewed data of patients who underwent EIN or CST surgery for tibia shaft fracture at our center from 2013 to 2018. The patient demographics, fracture characteristics, radiographic information, length of hospital stay, and medical expenses were recorded. All patients were clinically followed-up until they started to walk or for at least 6 months. The treatment outcomes and postoperative complications of the two procedures were compared.

RESULTS

Overall, 186 patients who underwent EIN and CST were included in the study. The EIN patients had more low-energy mechanism of injury. In radiographic evaluation, significant differences were observed in distributions of fracture classification and location. Moreover, associated fibula fractures were higher in the EIN group than in the CST group. The CST procedure had faster surgical time, cast duration and lower expenses, and longer hospitalization time. Although they required more clinical visits, patients in the EIN group began exercising and endured weight-bearing earlier than those in the CST group. The average time for bone healing was 68.5 days in the EIN group, and 69.6 days in the CST group. However, the CST provided slight better results of coronal correction than EIN. Moreover, CST patients had less malalignment (> 5°) in complications. None had delay union, nonunion, and shortening over 10 mm at final assessment.

CONCLUSIONS

Both EIN and CST patients showed similar treatment outcomes. Hence, not only the characteristics of the patient and fracture, but also the individual's situation and expectation should be considered when choosing the best approach.

Leg length discrepancy, overgrowth, and associated risk factors after a pediatric tibial shaft fracture

BACKGROUND

This study was performed to investigate leg length discrepancy (LLD), overgrowth, and associated risk factors after pediatric tibial shaft fractures.

MATERIALS AND METHODS

This study included 103 patients younger than 14 years of age (mean age 7.1 years; 75 boys, 28 girls) with unilateral tibial shaft fracture and a minimum follow-up of 24 months. LLD was calculated as the difference between the lengths of the injured and uninjured limbs. Overgrowth was calculated by adding the fracture site shortening from the LLD. Risk factors were assessed in patients with LLD < 1 cm and ≥ 1 cm and overgrowth < 1 cm and ≥ 1 cm.

RESULTS

Casting and titanium elastic nailing (TEN) were performed on 64 and 39 patients, respectively. The mean LLD and overgrowth were 5.6 and 6.4 mm, respectively. There were significant differences in sex (p = 0.018), age (p = 0.041), fibular involvement (p = 0.005), injury mechanism (p = 0.006), and treatment methods (p < 0.001) between patients with LLDs < 1 cm and ≥ 1 cm. There were significant differences in sex (p = 0.029), fibular involvement (p = 0.002), injury mechanism (p = 0.008), and treatment methods (p < 0.001) between patients with overgrowth < 1 cm and ≥ 1 cm. Sex and treatment methods were risk factors associated with LLD ≥ 1 cm and overgrowth ≥ 1 cm following pediatric tibial shaft fracture. The boys had a 7.4-fold higher risk of LLD ≥ 1 cm and 5.4-fold higher risk of overgrowth ≥ 1 cm than the girls. Patients who underwent TEN had a 4.3-fold higher risk of LLD ≥ 1 cm and 4.8-fold higher risk of overgrowth ≥ 1 cm than those treated by casting.

CONCLUSIONS

Patients undergoing TEN showed greater LLD and overgrowth than those undergoing casting, with boys showing greater LLD and overgrowth than girls. Surgeons should consider the possibility of LLD and overgrowth after pediatric tibial shaft fractures, especially when performing TEN for boys.

LEVEL OF EVIDENCE

Level III.

Pediatric tibial shaft and distal metaphyseal fractures

Objectives

This study aims to investigate the effects of associated factors like age, fracture level, accompanying fibular fractures and wound condition on healing by determining and comparing union scores of pediatric tibial fractures (PTFs).

Patients and methods

Forty-five patients with 46 PTFs (32 males, 13 females; mean age 9.5 years; range 2 to 16 years) who were treated by closed reduction and casting or operated between January 2016 and January 2019 were retrospectively evaluated. The union scores were evaluated at the end of fourth, sixth and eighth weeks and compared to each other. Effects of the age, associated fibular fractures, wound condition, fracture level and treatment type to union score were analyzed.

Results

Twenty-eight (60.9%) out of 46 PTFs had associated fibular fractures and 18 (39.1%) did not. Motor vehicle accident was the most frequent etiologic factor (47.8%). Thirty-four out of 46 fractures were closed tibial fractures (73.9%) and 12 had open wound (26.1%). There was a negative correlation between age and the union scores (p<0.001 for each week). No significant difference was observed between the union score of diaphyseal and metaphyseal fractures at the fourth, sixth, and eighth weeks. The union scores of each week were higher in the conservative group compared to operative group (p<0.001 for each week). Associated fibular fracture group had lower union scores compared to isolated tibial fracture group at fourth, sixth and eighth weeks. Likewise, the union scores of the open fracture group were lower than the closed fracture group (p<0.05 for each week).

Conclusion

Associated fibular fractures, open fractures and aging negatively affect union scores of PTFs. Attention should be paid, particularly in these conditions, during the selection of the operation type and the follow-up period of PTFs.

Elastic Stable Intramedullary Nailing of Pediatric Tibial Fractures

BACKGROUND

Most pediatric tibial shaft fractures (75%)1 can be treated nonoperatively; however, unstable and open fractures require surgical intervention. Titanium elastic nails have become a popular technique for fixation of pediatric tibial shaft fractures. They act as internal splints that impart relative stability to the fracture, promoting callus formation at the fracture site2.

DESCRIPTION

After the patient is placed in the supine position, the proximal tibial physis is marked using fluoroscopy. An anteromedial and anterolateral incision are made distal to the physis. Entry holes are created in the proximal part of the tibia, and appropriately sized titanium nails are introduced into the bone. Nail size should be 40% of the width of the canal, yielding 80% canal fill when 2 nails are used. The nails are prebent into a gentle C-shape to increase cortical contact at the apex so that 3-point fixation is achieved. The nails are passed to the fracture site, and the fracture is then reduced. The nails are then passed across the fracture site and stopped proximal to the distal tibial physis. The nails are then cut and tamped distally until there is just a short portion of nail left out of the proximal part of the tibia so that the nails can be removed once the fracture is healed. The wounds are then closed, and postoperative immobilization is applied.

ALTERNATIVES

Many pediatric tibial shaft fractures can be treated with closed reduction and cast immobilization. Open fractures, or fractures that fail nonoperative management, can be treated with external fixation, open reduction and internal fixation (ORIF), or intramedullary stabilization3.

RATIONALE

Anatomic reduction and fracture compression can be achieved with ORIF; however, a drawback to this technique is the lack of soft-tissue coverage in the diaphyseal area of the tibia, which can lead to infection and wound-healing problems4. External fixation has traditionally been the technique of choice for open tibial fractures; however, with the ability to use flexible tibial nails in both open and closed tibial fractures, external fixation is now reserved for open fractures with large soft-tissue defects or in fractures with segmental bone loss. Intramedullary flexible nailing can be used in both open and closed tibial fractures, provides excellent fracture fixation, and utilizes incisions that are more cosmetically appealing to patients5,6.

EXPECTED OUTCOMES

Outcomes following flexible nailing for pediatric tibial fractures are excellent. In a study of 19 patients undergoing flexible nailing for tibial shaft fractures, 18 had excellent or satisfactory results7. Compared with patients who had external fixation, those treated with flexible nails had less pain, shorter time to union, and better functional outcomes2. Compared with patients treated with ORIF, those who underwent flexible intramedullary nailing spent less time in the operating room and had lower rates of wound complications4. In the immediate postoperative period, clinicians should be aware of the risk of compartment syndrome, particularly in patients with high-energy injuries, older patients (>14 years old), and heavier patients (>50 kg)8. There is also an increased risk of soft-tissue irritation and fracture malunion in heavier patients treated with flexible nails9,10.

IMPORTANT TIPS

Nail size should be 80% of the canal diameter (e.g., two 4.0-mm nails should be chosen for a canal that measures 10 mm).Nails should be properly contoured to avoid corticotomy of the far cortex during insertion; apex of the bend should be positioned at the level of the fracture.During insertion, leave room to advance nails further after they are cut proximally.Do not bury the proximal nail tips beneath the cortex as extraction will be difficult.Ensure that the ends of the nails are not lying up against the proximal tibial physis as this may cause premature growth arrest.